Duration and outcome of orthotic treatment in children with clubfoot - a four-year follow-up national register study of Swedish children born between 2015 and 2017.

BACKGROUND: The Ponseti method for treating clubfoot consists of initial treatment with serial casting accompanied by achillotenotomy if needed, followed by the maintenance phase including treatment with a foot abduction orthosis (FAO) for at least four years. This study aimed to examine the duration, course, and outcome of orthotic treatment in children with clubfoot. METHODS: 321 children with clubfoot, born between 2015 and 2017, registered in the Swedish Pediatric Orthopedic Quality Register (SPOQ), were included in this prospective cohort study. Data on deformity characteristics and orthotic treatment were extracted. For children with bilateral clubfoot, one foot was included in the analysis. RESULTS: Of the 288 children with isolated clubfoot, 274 children (95.5%) were prescribed an FAO, and 100 children (35%) changed orthosis type before 4 years of age. Of the 33 children with non-isolated clubfoot, 25 children (76%) were prescribed an FAO, and 21 children (64%) changed orthosis type before 4 years of age. 220 children with isolated clubfoot (76%), and 28 children with non-isolated clubfoot (84%) continued orthotic treatment until 4 years of age or longer. Among children with isolated clubfoot, children ending orthotic treatment before 4 years of age (n = 63) had lower Pirani scores at birth compared to children ending orthotic treatment at/after 4 years of age (n = 219) (p = 0.01). It was more common to change orthosis type among children ending orthotic treatment before 4 years of age (p = 0.031). CONCLUSIONS: The majority of children with clubfoot in Sweden are treated with an FAO during the maintenance phase. The proportion of children changing orthosis type was significantly greater and the Pirani score at diagnosis was lower significantly among children ending orthotic treatment before 4 years of age. Long-term follow-up studies are warranted to fully understand how to optimize, and individualize, orthotic treatment with respect to foot involvement and severity of deformity. LEVEL OF EVIDENCE: II.

Diagnosis and Treatment of Idiopathic Congenital Clubfoot.

Idiopathic congenital clubfoot is the most common serious musculoskeletal birth defect in the United States and the world. The natural history of the deformity is to persist into adult life with a significant decrease in function and quality of life. The Ponseti method (serial casting, Achilles tenotomy, and bracing of the clubfoot) has become the most effective and accepted treatment of children born with clubfoot worldwide. The treatment is successful, particularly when the Ponseti-trained practitioner (often a pediatric orthopedic surgeon), the primary care clinician, and the family work together to facilitate success. An important factor in the ultimate success of the Ponseti method is parental understanding of the bracing phase. There is a very high rate of recurrent deformity when bracing is not done properly or is stopped prematurely. The importance of positive education and support for the parents to complete the entire treatment protocol cannot be overstated. The goal of treatment is a deformity-free, functional, comfortable foot. Ponseti clubfoot programs have been launched in most countries throughout the world, including many countries with limited resources. Ultimately, the goal is that every infant born with a clubfoot will have access to care with the Ponseti method. This clinical report is intended for medical practitioners who are involved in the care of pediatric patients with clubfoot. Understanding the standard of care will help these practitioners to care for patients and their families.

Biceps tenotomy versus tenodesis: patient-reported outcomes and satisfaction.

BACKGROUND: Biceps tenotomy and tenodesis are surgical treatments for pathology of the proximal tendon of the long head of the biceps. There is debate over which procedure provides better patient outcomes. PURPOSE: Compare patient-reported outcomes and satisfaction between biceps tenotomy and tenodesis. METHODS: This retrospective cohort study including all patients undergoing arthroscopic biceps tenodesis or tenotomy as part of more extensive shoulder surgery with a single surgeon. Concomitant procedures included rotator cuff repair, subacromial decompression, acromioclavicular joint resection, and debridement. Patients 36-81 years old were contacted by phone at > 2-year post-operatively to complete a biceps-specific outcome questionnaire. Subject decision not to participate was the sole exclusion criterion. Satisfaction scores and frequencies of potential biceps-related downsides (biceps cramping/spasms, biceps pain, shoulder pain, weakness, cosmetic deformity) were analyzed for the effects of procedure, sex, and age. RESULTS: Satisfaction score distributions were similar between patients with tenodesis and patients with tenotomy (χ2 = 8.34, P = 0.08), although slightly more patients with tenodesis than patients with tenotomy reported being satisfied or very satisfied (96% versus 91%). Perceived downsides occurred more frequently among patients with tenotomy than in patients with tenodesis: 59% of patients with tenotomy reported ≥ 1 downside, versus 37% of patients with tenodesis (P < 0.01). In patients reporting ≥ 1 downside, distributions of total downsides differed between procedures (χ2 = 10.04, P = 0.04): patients with tenotomy were more likely to report multiple concurrent downsides than were patients with tenodesis (31% versus 16%). Each individual downside tended to be reported as present by a greater proportion of patients with tenotomy than patients with tenodesis. Sex had no effect on satisfaction or downsides, but there was a trend for older patients to report higher satisfaction and fewer downsides. CONCLUSIONS: Biceps tenotomy and tenodesis are both viable treatments for proximal biceps tendon pathology, yielding high patient satisfaction. There were trends toward greater satisfaction and fewer problems in patients with tenodesis. Still, younger patients with tenodesis did report perceived downsides. Alternatively, older patients tended to be more satisfied with both procedures overall. Regardless of procedure, most patients receiving either tenotomy or tenodesis would undergo their respective surgery again. LEVEL OF EVIDENCE: Level III evidence, retrospective comparative cohort study.

Is arthroscopic repair superior to biceps tenotomy and tenodesis for type II SLAP lesions? A meta-analysis of RCTs and observational studies.

OBJECTIVE: Labral repair and biceps tenotomy and tenodesis are routine operations for type II superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their superiority is lacking. We conducted this systematic review and meta-analysis to compare the clinical outcomes of arthroscopic repair versus biceps tenotomy and tenodesis intervention. METHODS: The eight studies were acquired from PubMed, Medline, Embase, CNKI, and Cochrane Library. The data were extracted by two of the coauthors independently and were analyzed by RevMan 5.3. Mean differences (MDs), odds ratios (ORs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration's Risk of Bias Tool and Newcastle-Ottawa Scale were used to assess risk of bias. RESULTS: Eight studies including two randomized controlled trials (RCTs) and six observational studies were assessed. The methodological quality of the trials ranged from low to moderate. The pooled results of UCLA score, SST score, and complications showed that the differences were not statistically significant between the two interventions. The difference of ASES score and satisfaction rate was statistically significant between arthroscopic repair and biceps tenotomy and tenodesis intervention, and arthroscopic biceps tenotomy and tenodesis treatment was more effective. Sensitivity analysis proved the stability of the pooled results, and there were too less included articles to verify the publication bias. CONCLUSIONS: Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions. Arthroscopic biceps tenotomy and tenodesis treatment provides better clinical outcome in ASES score and satisfaction rate and comparable complications compared with arthroscopic repair treatment. In view of the heterogeneity and confounding factors, whether these conclusions are applicable should be further determined in future studies.

The need for Achilles tenotomy in the Ponseti method: Is it predictable at the initiation or during the treatment?

The aim of this study was to determine whether the need for tenotomy can be predicted at the initiation or during the treatment of the clubfoot treatment according to the Ponseti method. One hundred and eight feet of 77 babies who required tenotomy and who did not were compared statistically according to the parameters of sex, side, bilaterality, presentation day, number of casts, Pirani scores, and the percentage change in Pirani scores, respectively. The mean number of casts required, the initial Pirani scores, and the percentage change in Pirani scores were significantly different between the groups that required tenotomy and the groups that did not (P=0.0001). Pirani scores at the beginning and the percentage change in Pirani scores during the treatment can be used to estimate the need for Achilles tenotomy.

Surgical Trends in the Treatment of Superior Labrum Anterior and Posterior Lesions of the Shoulder: Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database.

BACKGROUND: After failure of nonoperative treatment, repair has long been the primary treatment option for symptomatic superior labrum anterior and posterior (SLAP) lesions of the shoulder. There is growing evidence to support both biceps tenotomy and tenodesis as effective alternative treatments for SLAP lesions. HYPOTHESES: For patients with isolated SLAP lesions, the frequency of SLAP repair has decreased, while treatment with biceps tenodesis and tenotomy has increased. Similar trends are expected in patients with SLAP lesions undergoing concomitant rotator cuff repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A query of the American Board of Orthopaedic Surgery part II database was performed from 2002 to 2011. The database was searched for patients with isolated SLAP lesions undergoing SLAP repair, open biceps tenodesis, arthroscopic biceps tenodesis, or biceps tenotomy. The database was then queried a second time for patients undergoing arthroscopic rotator cuff repair with concomitant SLAP repair, biceps tenodesis, or biceps tenotomy. RESULTS: From 2002 to 2011, there were 8963 cases reported for the treatment of an isolated SLAP lesion and 1540 cases reported for the treatment of SLAP lesions with concomitant rotator cuff repair. For patients with isolated SLAP lesions, the proportion of SLAP repairs decreased from 69.3% to 44.8% (P < .0001), while biceps tenodesis increased from 1.9% to 18.8% (P < .0001), and biceps tenotomy increased from 0.4% to 1.7% (P = .018). For patients undergoing concomitant rotator cuff repair, SLAP repair decreased from 60.2% to 15.3% (P < .0001), while biceps tenodesis or tenotomy increased from 6.0% to 28.0% (P < .0001). There was a significant difference in the mean age of patients undergoing SLAP repair (37.1 years) versus biceps tenodesis (47.2 years) versus biceps tenotomy (55.7 years) (P < .0001). CONCLUSION: Practice trends for orthopaedic board candidates indicate that the proportion of SLAP repairs has decreased over time, with an increase in biceps tenodesis and tenotomy. Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair.

Lesiones proximales y distales del tendón del bíceps braquial: Revisión clínica y ecográfica / Proximal and distal biceps brachii tendon injuries: Clinical and ultrasound review

Las características anatómicas especiales del tendón del bíceps se relacionan con su doble origen tendinoso, que confluye para formar un músculo con una inserción tendinosa distal única. En general, las roturas proximales se producen de forma traumática en varones de edad media, cuando realizan un movimiento excéntrico con el codo en flexión. Sin embargo, mientras que las roturas del bíceps proximal son mas frecuentes y requieren un tratamiento habitualmente conservador, las disrupciones del tendón distal son menos comunes y por el contrario requieren un tratamiento quirúrgico. La ecografía tiene muchas ventajas en el examen de la mayoría de los tendones, como el bíceps braquial proximal. Sin embargo, la disposición anatómica del bíceps distal, hace que la visualización del tendón conjunto y de su inserción radial a menudo sea poco fiable. Las lesiones proximales representan más del 90%de las que se producen en el bíceps braquial. Los procesos patológicos que se pueden observar ultrasonográficamente en este tendón son la tendinosis, tenosinovitis, roturas y luxaciones y el tratamiento sigue siendo un desafío. La dificultad radica en determinar si la lesión es aislada o es concomitante con patología del manguito rotador o con inestabilidad. Las roturas sintomáticas del tendón del bíceps pueden someterse a desbridamiento, tenotomía, o tenodesis si las medidas conservadoras no proporcionan alivio. En la porción distal se producen tendinosis, bursitis y roturas parciales o totales. El tratamiento conservador, está típicamente reservado para las lesiones parciales con poco compromiso funcional, y para los pacientes no aptos para la cirugía, aunque el tratamiento de las roturas completasen los atletas es principalmente quirúrgico y la decisión de cuándo tratar los desgarros parciales no está muy clara (AU)

The special anatomical features of the biceps tendon are the result of its dual original tendon, which converge to form a muscle with a single distal tendon attachment. In general, the proximal breaks are produced traumatic middle-aged men, when they perform an eccentric movement with the elbow flexed. However, while the proximal biceps tears are more common and usually require conservative treatment, distal tendon disruptions are less common and instead require surgical treatment. Ultrasound has many advantages in the examination of most of the tendons, and proximal brachial biceps. However, the anatomical arrangement of the distal biceps, makes viewing the radial insertion is often unreliable. Proximal lesions over 90% of which occur in the biceps brachii. Pathological processes that can be observed ultrasonographically in this tendon are tendinosis, tenosynovitis, ruptures and dislocations and treatment remains a challenge. The difficulty is in determining if the injury is isolated or is concomitant with rotator cuff pathology or with instability. Symptomatic ruptures of the biceps tendon may be treated debridement, tenotomy, or tenodesis if conservative measures fail to provide relief. In the distal portion occurring tendinosis, bursitis and partial or total tear. Conservative treatment is typically reserved for partial injuries with little functional compromise, and for patients unfit for surgery but the treatment of complete ruptures in athletes is primarily surgical, although the decision of when to treat partial tears is not so clear (AU)

From cutting to casting: impact and initial barriers to the Ponseti method of clubfoot treatment in China.

In 2005, a nationwide clubfoot treatment program focused on the Ponseti method -an effective, affordable and minimally-invasive method- was initiated in China. The purpose of this study was to evaluate and identify barriers to the program. A qualitative study (rapid ethnographic study) was conducted using semi-structured interviews of 44 physicians who attended four of the 10 Ponseti training workshops, focus groups with parents of children with clubfoot, and observation. Several barriers to the Ponseti method are quite unique due to China's size, socio-economics, culture, politics, and healthcare systems. The barriers were classified into seven themes: (i) physician education, (ii) caregiver compliance, (iii) culture, (iv) public awareness, (v) poverty, (vi) financial constraints for physicians/hospitals, and (vii) challenges of the treatment process. A number of suggestions that could be helpful in reducing or eliminating the effects of these barriers were also identified: (i) pamphlets explaining clubfoot and treatment for caregivers, (ii) directories of Ponseti providers, (iii) funding/financial support, and (iv) improving public awareness. The information from this study provides healthcare planners with knowledge to assist in meeting the needs of the population and continued implementation of effective and culturally appropriate awareness and treatment programs for clubfoot throughout China.

Ponseti clubfoot management: changing surgical trends in Nigeria.

BACKGROUND: Congenital clubfoot treatment continues to be controversial particularly in a resource-constrained country. Comparative evaluation of clubfoot surgery with Ponseti methods has not been reported in West Africa. OBJECTIVES: To determine the effects of Ponseti techniques on clubfoot surgery frequency and patterns in Nigeria. METHODS: This was a prospective hospital-based intention-to-treat comparative study of clubfoot managed with Ponseti methods (PCG) and extensive soft tissue surgery (NPCG). The first step was a nonselective double-blind randomization of clubfoot patients into two groups using Excel software in a university teaching hospital setting. The control group was the NPCG patients. The patients' parents gave informed consent, and the medical research and ethics board approved the study protocol. Biodata was gathered, clubfoot patterns were analyzed, Dimeglio-Bensahel scoring was done, the number of casts applied was tallied, and patterns of surgeries were documented. The cost of care, recurrence and outcomes were evaluated. Kruskal-Wallis analysis and Mann-Whitney U technique were used, and an alpha error of < 0.05 at a CI of 95% were taken to be significant. RESULTS: We randomized 153 clubfeet (in 105 clubfoot patients) into two treatment groups. Fifty NPCG patients (36.2%) underwent manipulation and extensive soft tissue surgery and 55 PCG patients (39.9%) were treated with Ponseti methods. Fifty-two patients of the Ponseti group had no form of surgery (94.5% vs. 32%, p<0.000). Extensive soft tissue surgery was indicated in 17 (34.0%) of the NPCG group, representing 8.9% of the total of 191 major orthopaedic surgeries within the study period. Thirty-five patients (70.0%) from the NPCG group required more than six casts compared to thirteen patients (23.6%) of the PCG (p<0.000). The mean care cost was high within the NPCG when compared to the Ponseti group (48% vs. 14.5%, p<0.000). The Ponseti-treated group had fewer treatment complications (p<0.003), a lower recurrence rate (p<0.000) and satisfactory early outcome (p<0.000). CONCLUSION: Major clubfoot surgery was not commonly indicated among patients treated with the Ponseti method. The Ponseti clubfoot technique has reduced total care costs, cast utilization, clubfoot surgery frequency and has also changed the patterns of surgery performed for clubfoot in Nigeria.